Comparison of topical tobramycin—dexamethasone with dexamethasone—neomycin—polymyxin and neomycin—polymyxin—gramicidin for control of inflammation after cataract surgery: Results of a multicenter, prospective, three-arm, randomized, double-masked, controlled, parallel-group study

Clinical features and comprehensive treatment of persistent corneal epithelial dysfunction after cataract surgery

OBJECTIVE

Evaluation of clinical efficacy and safety of tobramycin/dexamethasone eye ointment in treating persistent corneal epithelial dysfunction (PED) after cataract surgery.

METHODS

26 cases diagnosed as PED after cataract surgery accept the tobramycin/dexamethasone ophthalmic ointment and intense pulse light treatment in the Xiamen University of Xiamen eye center between September 2016 and April 2022 were retrospectively analyzed, mainly including clinical manifestations, characteristics of morphological changes imaged by in vivo confocal microscopy, meibomian glands infrared photography, lipid layer thickness (LLT), management and therapeutic effects.

RESULTS

There were 26 eyes, include 8(35%) males and 15(65%) females with an average age of 69.6 ± 5.2 years(50 to 78 years). The mean hospitalization time was (18.4 ± 7.5) days after cataract surgery. Twenty patients had meibomian gland dysfunction. Infrared photography revealed varying loss in the meibomian glands, with a mean score of 3.8 ± 1.2 for gland loss. The mean LLT was 61.6 ± 8.4 nm. After treatment, 20 patients were cured, and 3 received amniotic membrane transplantation. After treatment, the uncorrected visual acuity (UCVA) and best-corrected vision activity (BCVA) improved (P < 0.001), and there was no significant difference in intraocular pressure (IOP) before and after treatment (P > 0.05).

CONCLUSIONS

The early manifestation of PED after surgery is punctate staining of the corneal epithelium. Tobramycin and dexamethasone eye ointment bandages have a good repair effect. The meibomian gland massage combined with intense pulse light treatment can effectively shorten the course of the disease.

Risk of intraocular pressure elevation after topical steroids in children and adults: A systematic review

Topical steroids may induce a rise in intraocular pressure. The risk may increase with prolonged use, high frequency of administration, young age, higher ocular penetrance and higher anti-inflammatory potency. We aimed to study this relationship by comparing published rates of intraocular pressure elevation following administration of topical steroids and compared the risk of higher versus lower dosage regimes, high- versus low-potency/penetration steroids and adults versus children. Data sources used were Ovid Embase, Ovid Medline, the Cochrane Central Register of Controlled Trials, Web of Science, Scopus, CINHAL Plus and LILACS. Eligible studies were randomised controlled trials of topical steroids versus any other topical steroid, nonsteroidal anti-inflammatory drugs, placebo or vehicle, or a different mode of administration administered for 7 days or longer that reported intraocular pressure elevation from baseline as >10, 6-15 or >15 mm Hg in adults or children. Risks of bias were reviewed using the GRADE quality approach. Data were extracted into the software package, RevMan, Version 5 (Cochrane Collaboration). In total, 43 studies were included. Meta-analysis was not possible. Topical steroids of lower anti-inflammatory potency, and with reduced intraocular penetration, are associated with reduced incidence of intraocular pressure elevation. A comparison of data in children and adults is limited by the use of different reporting systems. The principal obstacle to meta-analysis is the different reporting systems used to categorise intraocular pressure elevation. We recommend future studies should report intraocular pressure elevation >10 mm Hg from baseline to allow meta-analysis of data.

Transzonular Triamcinolone-Moxifloxacin Versus Topical Drops for the Prophylaxis of Postoperative Inflammation After Cataract Surgery

Purpose: To compare the safety and efficacy of an intraoperative transzonular injection of triamcinolone-moxifloxacin (Imprimis' Tri-Moxi 15 mg/1 mg/mL) to topical drops in patients undergoing cataract surgery. Methods: Between January 2017 and October 2017, patients undergoing phacoemulsification cataract surgery by a single surgeon at the Penn State Eye Center were offered a single intraoperative injection of transzonular triamcinolone-moxifloxacin in lieu of perioperative drops. Between November 2017 and July 2018, the transzonular injection was not offered, and all patients who underwent surgery by the same surgeon received a drop regimen consisting of polymyxin b/trimethoprim and prednisolone acetate 1%. Patients were seen 1 day, 1 week, and 6-9 weeks postoperatively. Outcome measures included incidence of intraoperative complications, postoperative breakthrough inflammation, cystoid macular edema, and infectious sequela. Results: Of the 198 eyes, 99 from 73 patients received the injection and 99 from 82 patients received topical drops. One (1%) intraoperative posterior capsule tear occurred in each group. Eleven (11.1%) eyes in the injection group and 3 (3%) in the drop group experienced symptomatic breakthrough inflammation necessitating treatment (P = 0.0488). One (1%) eye in the injection group and zero (0%) in the drop group developed clinically significant macular edema (P = 1.0). No instances of elevated intraocular pressure or infectious sequela occurred in either group (P = 1.0). Conclusions: Transzonular injection of triamcinolone-moxifloxacin may be associated with an increased incidence of breakthrough inflammation compared to topical drops.

Proficiency of eye drop instillation in postoperative cataract patients in Ghana

OBJECTIVE

The purpose of the study was to evaluate the efficacy of postoperative instruction on proficiency of eye drop instillation following cataract surgery, and to determine whether such proficiency correlates with the prevalence and/or duration of irritation and pain experienced in operated eyes.

DESIGN

This was a prospective, nonrandomized control trial with an educational intervention conducted via a single eye clinic in Accra, Ghana.

PARTICIPANTS

The 218 subjects who completed the study were postoperative cataract surgery patients whose surgery had been funded by the nongovernmental organization Unite for Sight.

METHODS

Patients were evaluated on their ability to administer eye drops correctly on their first attempt on postoperative day one. If unsuccessful, patients were given an educational session that consisted of verbal instructions and an educational video. Both groups (successful and unsuccessful) on the first postoperative day were tested again for proficiency on postoperative day 30. The baseline group was evaluated only on postoperative day 30 and consisted of 36 patients.

RESULTS

Of the 133 patients who received the educational session on eye drop instillation, 112 (84%) exhibited proficiency on postoperative day 30 as compared with 29 of 49 patients (59%) who did not receive the intervention. Additionally, there were fewer reports of pain and irritation following cataract extraction in the patients who received the educational session.

CONCLUSION

This study supports the efficacy of patient education in improving proficiency in eye drop instillation and in reducing pain and irritation following cataract extraction surgeries.

A multicenter, randomized, parallel-group, clinical trial comparing the safety and efficacy of loteprednol etabonate 0.5%/tobramycin 0.3% with dexamethasone 0.1%/tobramycin 0.3% in the treatment of Chinese patients with blepharokeratoconjunctivitis

OBJECTIVE

To compare the efficacy and safety of loteprednol etabonate 0.5%/tobramycin 0.3% (LE/T) and dexamethasone 0.1%/tobramycin 0.3% (DM/T) ophthalmic suspensions in a Chinese population with ocular inflammation associated with blepharokeratoconjunctivitis (BKC).

RESEARCH DESIGN AND METHODS

This study was a multicenter, randomized, investigator-masked, parallel-group clinical trial. Patients aged ≥18 years with a clinical diagnosis of BKC in at least one eye received LE/T or DM/T administered 4 times daily for 2 weeks. At baseline and on days 3, 8, and 15 (visits 2, 3, and 4), clinical assessments of ocular signs and symptoms, visual acuity (VA), biomicroscopy, and intraocular pressure (IOP) were performed in both eyes.

MAIN OUTCOME MEASURES

The primary efficacy endpoint was the change from baseline (CFB) to visit 4 in the signs and symptoms composite score in designated study eyes using a non-inferiority metric to compare LE/T to DM/T. Safety evaluation included adverse events, biomicroscopy findings, and changes in VA and IOP.

CLINICAL TRIAL REGISTRATION

NCT number, NCT01028027.

RESULTS

A total of 308 patients were included in the per protocol population (n = 156 LE/T, n = 152 DM/T). A significant CFB in composite signs and symptoms was seen with both treatments at each follow-up visit (p < 0.0001). The mean (SD) CFB at visit 4 was -11.63 (4.56) and -12.41 (4.71) in the LE/T and DM/T groups, respectively, and the upper bound of the 90% confidence interval for the difference was less than the prespecified non-inferiority margin. Comparable results were found for secondary efficacy outcomes. Patients treated with DM/T experienced a significantly greater increase in mean CFB in IOP compared to those treated with LE/T at all follow-up visits (p ≤ 0.0186) and nearly twice as many IOP elevations ≥5 mmHg (p = 0.0020).

CONCLUSION

Treatment with LE/T was at least as effective as DM/T in Chinese patients with BKC and had a better safety profile with respect to change in IOP.

Efficacy and tolerability of a fixed-dose moxifloxacin - dexamethasone formulation for topical prophylaxis in LASIK: a comparative, double-masked clinical trial

Purpose

To compare the efficacy and tolerability of a fixed-dose combination of 0.5% moxifloxacin and 0.1% dexamethasone formulation (MFLX/DEX) vs conventional dosing with both agents dosed separately for prophylaxis after laser-assisted in situ keratomileusis (LASIK).

Methods

A prospective, randomized, double-masked, parallel-group study of 64 patients undergoing bilateral LASIK. Patients received either combined MFLX/DEX and placebo or moxifloxacin and dexamethasone dosed separately in both eyes. Baseline and postoperative assessments were made on surgery days –2, 1, 3, 8, and 15 and consisted of uncorrected visual acuity (UCVA), intraocular pressure (IOP), severity of inflammation, endothelial cell loss, ocular pain, burning, and itching sensation. The posterior segment was evaluated at the screening and exit visits.

Results

Of the 64 patients treated, 7 eyes did not meet the inclusion criteria and were excluded from the analysis. No ocular infection or persistent inflammation developed. Postoperatively there were no statistical differences between treatments for most parameters measured. More eyes in the combined MFLX/DEX group reported pruritus and burning post operatively; however, differences were also observed at baseline.

Conclusion

Topical prophylaxis with MFLX/DEX eye drops was well tolerated and is therapeutically equivalent to conventional dosing with moxifloxacin and dexamethasone from individual bottles.

Efficacy and tolerability of a combined moxifloxacin/dexamethasone formulation for topical prophylaxis in phacoemulsification: an open-label single-arm clinical trial

Background. The use of a fixed-combination antibiotic corticosteroid for infection prophylaxis in Asian patients undergoing phacoemulsification has not been reported. Methods. A 15-day, open-label, single-arm trial of 64 patients for phacoemulsification with intraocular lens (IOL) implantation is described. Patients applied moxifloxacin 0.5%/dexamethasone 0.1% (Vigadexa) eye drops four times daily before and until 15 days after surgery. Anterior chamber (AC) reaction, visual acuity, ocular pain and signs, and intraocular pressure (IOP) were assessed at baseline and on postoperative days 1, 3, 8, and 15. Results. At day 15, 55 (91.7%) patients scored 0 (<5 cells) in AC reaction. No surgery-related infection occurred. Mean best-corrected visual acuity improved 0.5 logMAR from baseline to 0.0 logMAR (P < .0001). Mean IOP remained at 12-13 mm Hg over the 15-day treatment. Only 2 patients (3.1%) reported minimum ocular pain. Two (3.1%) patients were shifted to prednisolone acetate for severe inflammation. At the end of the study period, 8.3% were given fluorometholone for 1 week for AC reaction grade >0. No drug-related adverse event was reported. Conclusion. Following phacoemulsification and IOL implantation, the topical combination moxifloxacin 0.5%/dexamethasone 0.1% was effective in preventing infection and controlling inflammation and was well tolerated.

Efficacy and safety of netilmycin/dexamethasone preservative-free and tobramycin/dexamethasone-preserved fixed combination in patients after cataract surgery

PURPOSE

To compare the efficacy and safety of preservative-free Netilmycin/Dexamethasone with that of preserved Tobramycin/Dexamethasone, postcataract surgery.

METHODS

Prospective, randomized, single-blind study on patients submitted to phacoemulsification. During preoperatory visits, at 7 and 21 days conjunctival hyperemia, corneal edema, Tyndall, Shirmer I, corneal and conjunctival lissamine green and fluorescein staining, and intraocular pressure (IOP) were recorded. Postoperative pain (at day 7) and the subjective tolerability (at day 21) were investigated.

RESULTS

Eighty patients completed the study and the data collected were analyzed (44 on Netilmycin/Dexamethasone). Regarding the primary efficacy variable, intraocular inflammation, no microbial events were recorded, but aqueous flare was significantly lower with Tobramycin/Dexamethasone at 1 week (P = 0.002). Regarding secondary efficacy variables, conjunctival hyperemia was lower in patients under Tobramycin/Dexamethasone (P < 0.001), but corneal edema and ocular pain were similar. Regarding safety, no significant differences on ocular surface status were recorded. Both formulations were well tolerated, but Tobramycin/Dexamethasone caused an increased IOP at 1 week (P < 0.0001).

CONCLUSIONS

Both the studied fixed combinations are safe and effective in controlling postoperative inflammation and preventing postoperative ocular infections. Tobramycin/Dexamethasone has a quicker anti-inflammatory effect but needs IOP monitoring. Further studies on more patients using a sounder scientific design are needed to confirm our findings.

Intraocular lens as a drug delivery system for dexamethasone

PURPOSE

To evaluate the effect of an intraocular lens (IOL) coated with dexamethasone on postoperative inflammation after cataract surgery.

METHODS

Clear lens extraction was performed bilaterally in eight 8-week-old rabbits. An uncoated silicone IOL (CeeOn; AMO, Santa Ana, CA, USA) was implanted in one randomly selected eye. In the other eye, the same silicone IOL model was implanted but was coated with dexamethasone. Aqueous humour was obtained preoperatively and on days 1, 3, 7, 14 and 28 postoperatively. Three inflammatory parameters were measured and compared between the eyes: prostaglandin E2 (PGE2), white blood cell (WBC) count and protein content. The animals were killed on day 28 postoperatively.

RESULTS

PGE2 levels measured on days 1, 3 and 7 were significantly lower in eyes with a coated IOL compared to eyes with an uncoated IOL (p < 0.01). The WBC count was significantly lower in eyes with a coated IOL on days 1 (p < 0.01) and 3 (p < 0.05). There was significantly less protein in eyes with a coated IOL on days 1 and 3 (p < 0.01).

CONCLUSION

Coating a silicone IOL with dexamethasone significantly reduced postoperative inflammation after clear lens extraction in rabbits.

Polymyxins: A Review of the Current Status Including Recent Developments

Introduction: Polymyxins have become the drug of choice for treatment of multidrug-resistant gram-negative bacilli infections in Singapore, simply because these pathogens are only susceptible to either aminoglycosides and polymyxins, or polymyxins only. Furthermore, there is no new antibiotic in the pipeline that targets these difficult-to-treat infections. Materials and Methods: All published literatures (up to end of February 2008) regarding polymyxins are included for review. Results: This review serves to give a summary of polymyxins from the current available literature, highlighting relevant clinical studies and information that help to guide informed prescription of polymyxins, should the need arise. Conclusions: However, there are substantial information gaps that needed to be filled urgently, to preserve the clinical utility of this very last line of antibiotic. Key words: Acinetobacter baumannii, Colistin, Multidrug resistance, Polymyxin B, Pseudomonas aeruginosa

Tolerability of loteprednol/tobramycin versus dexamethasone/tobramycin in healthy volunteers: results of a 4-week, randomized, double-masked, parallel-group study

OBJECTIVE

To compare the ocular comfort and tolerability of loteprednol etabonate 0.5%/tobramycin 0.3% (LE/T; Zylet) with dexamethasone 0.1%/tobramycin 0.3% (DM/T; TobraDex) in healthy volunteers.

RESEARCH DESIGN AND METHODS

In this multicenter, randomized, double-masked, parallel-group study, healthy volunteers (n = 306) were randomized to receive LE/T or DM/T four times per day for 28 days. Subjects recorded subjective ratings for seven comfort/tolerability parameters using an electronic patient diary (EPD). The primary endpoint was the difference at week 4 from the ratings of an artificial tear at baseline in comfort/tolerability parameters between treatment groups, using a noninferiority paradigm.

CLINICAL TRIALS REGISTRATION

ClinicalTrials. gov, NCT 00532961.

RESULTS

The 97.5% confidence intervals for the lower bound were within -10 for all of the seven comfort/ tolerability parameters evaluated (pain, stinging/burning, irritation, itchiness, foreign-body sensation, dryness, and light sensitivity). Secondary analysis revealed small but significant within-treatment differences in pain favoring LE/T over tears and in light sensitivity favoring tears over DM/T (p < 0.01). Small between-treatment differences in the changes from baseline tear ratings to individual study visits favored LE/T for pain, stinging/burning, irritation, itchiness, foreign-body sensation, and light sensitivity at visit 4 (p < or = 0.04); for pain, stinging/burning, and foreignbody sensation at visit 5 (p < or = 0.03), and for dryness and light sensitivity at visit 6 (p < or = 0.05).

CONCLUSIONS

LE/T satisfied all conditions of noninferiority to DM/T in comfort and tolerability. Subjects receiving LE/T were more likely to report better ocular comfort/tolerability ratings relative to baseline artificial tears than subjects receiving DM/T.

LIMITATIONS

The study population consisted of healthy volunteers.

Effectiveness of a new tobramycin (0.3%) and dexamethasone (0.05%) formulation in the treatment of experimental Pseudomonas keratitis

OBJECTIVE

To quantitatively determine, in a Pseudomonas keratitis model, the anti-inflammatory and bactericidal properties of a new formulation of tobramycin (0.3%) and dexamethasone (0.05%) that utilizes a xanthan gum vehicle.

RESEARCH METHODS

In a randomized and masked fashion, rabbit corneas (n>/=16 eyes per group) were intrastromally injected with 10(3) colony-forming units (CFU) of P. aeruginosa. Eyes were untreated or were administered a single drop every 15 min between 16 and 17 h postinfection (PI) and then a single drop every 30 min between 17 and 22 h PI, a total of 15 drops of either 0.1% dexamethasone and 0.3% tobramycin (TobraDex; Tdex) or a new formulation 0.3% tobramycin and 0.05% dexamethasone with xanthan gum (TobraDex ST; ST). Slit lamp examination scores (SLE+/-SEM) were derived from grading seven parameters at 22 h PI. Rabbits were sacrificed at 23 h PI and the log CFU+/-SEM per cornea was determined.

RESULTS

Untreated eyes had SLE scores of 11.11+/-0.43 and had log CFU of 7.27+/-0.06. Eyes treated with Tdex, as compared to the untreated eyes, had significantly lower SLE scores (7.39+/-0.21, p<0.0001) and significantly fewer bacteria (6.32+/-0.29 log CFU, p=0.0213). Eyes treated with ST had a SLE score (6.56+/-0.19) that was significantly lower than both the untreated eyes (p<0.0001) and the eyes treated with Tdex (p=0.0124). Furthermore, eyes treated with ST had significantly fewer log CFU (5.78+/-0.30) than untreated eyes (p=0.0001) or eyes treated with Tdex (p=0.0434).

CONCLUSIONS

The ST formulation with xanthan gum demonstrated statistically superior anti-inflammatory and bactericidal properties as compared to Tdex.

LIMITATIONS

Variations in inoculation procedures produced limited eye-to-eye differences in the infection.

Effects of loteprednol/tobramycin versus dexamethasone/tobramycin on intraocular pressure in healthy volunteers

PURPOSE

To compare the steroid-induced intraocular pressure (IOP) and other ocular adverse effects of loteprednol etabonate 0.5% and tobramycin 0.3% ophthalmic suspension with those of dexamethasone 0.1% and tobramycin 0.3% ophthalmic suspension.

METHODS

Three hundred six healthy volunteers received either loteprednol etabonate/tobramycin (n = 156) or dexamethasone/tobramycin (n = 150) at 4-hour intervals 4 times a day in both eyes for 28 days in this randomized, double-masked, multicenter, parallel-group trial. IOP, visual acuity (VA), and ocular health were assessed at all study visits (days 1, 3, 8, 15, 22, and 29), whereas undilated direct ophthalmoscopy was completed at the baseline and final visits. Adverse events (AEs) were assessed at all follow-up visits.

RESULTS

The number of subjects experiencing IOP increases of >or=10 mm Hg from baseline at any study visit for the loteprednol etabonate/tobramycin group (3 subjects, 1.95%) was significantly lower than that for the dexamethasone/tobramycin group (11 subjects, 7.48%; P = 0.0280), as were mean changes from baseline IOP (P < 0.05 at all visits). The lowest VA recorded for any subject at any visit was 20/40 and reductions of >or=2 lines at any visit were observed in 14 (4.55%) eyes for loteprednol etabonate/tobramycin and in 23 (7.82%) eyes for dexamethasone/tobramycin (P = 0.1257). Both treatments were well tolerated.

CONCLUSIONS

Loteprednol/tobramycin was significantly less likely to produce elevations in IOP than was dexamethasone/tobramycin in healthy subjects treated for 28 days. Both loteprednol etabonate/tobramycin and dexamethasone/tobramycin were well tolerated with low risks for systemic AEs and ocular AEs other than elevation in IOP for dexamethasone/tobramycin.

Ocular distribution, bactericidal activity and settling characteristics of TobraDex ST ophthalmic suspension compared with TobraDex ophthalmic suspension

INTRODUCTION

TobraDex ophthalmic suspension (tobramycin 0.3%, dexamethasone 0.1%; Alcon Laboratories Inc, Fort Worth, Tex) is frequently used for inflammatory ocular conditions where a risk of bacterial ocular infection exists. A new formulation, TobraDex ST ophthalmic suspension (tobramycin 0.3%, dexamethasone 0.05%, Alcon), utilises a novel suspension technology to reduce viscosity and help prevent settling in the container.

METHODS

A rabbit model that closely mimics the human eye and a clinical study with cataract patients was used to compare the pharmacokinetics and tissue permeability of TobraDex ST and TobraDex. An in-vitro model was used to assess the bactericidal activity using the rabbit tear concentrations of tobramycin 10 minutes after a single topical dose.

RESULTS

Concentrations of both tobramycin and dexamethasone were greater in the tear film and ocular tissues of rabbits treated with TobraDex ST. There was an 8.3-fold increase in tobramycin concentration in the rabbit tear film 10 minutes after dosing with TobraDex ST compared with TobraDex. Concentrations of tobramycin and dexamethasone in ocular tissues from rabbits exposed to TobraDex ST were up to 12.5-fold greater relative to TobraDex. The in-vitro bactericidal activity (>99.9% kill, 3-log reduction) of TobraDex ST toward tobramycin-resistant and methicillin-resistant Staphylococcus aureus occurred in 90 minutes. TobraDex ST killed Streptococcus pneumoniae 3-log in 5 minutes. TobraDex had no activity toward tobramycin-resistant, methicillin-resistant S. aureus and required approximately 120 minutes for 3-log reduction of S. pneumoniae. In humans, the mean ratio of dexamethasone levels in the aqueous humour at 1 hour was 1.17 in favour of TobraDex ST.

CONCLUSION

TobraDex ST demonstrated improved suspension formulation characteristics, enhanced pharmacokinetic distribution and improved bactericidal characteristics, and may provide a useful alternative as compared to TobraDex.

Efficacy and tolerability of a combined moxifloxacin/dexamethasone formulation for topical prophylaxis and reduction of inflammation in phacoemulsification: a comparative, double masked clinical trial

PURPOSE

To compare the efficacy and safety of a combined 0.5% moxifloxacin and 0.1% dexamethasone formulation (Vigadexa) versus conventional dosing with 0.5% concomitant moxifloxacin (Vigamox) and 0.1% dexamethasone (Maxidex) for the prevention of infection and control of inflammation after cataract surgery.

SETTING

The ophthalmology clinic and outpatient surgery suite of a public hospital in Brazil.

METHODS

A prospective, randomized, double-masked, parallel-group study of 139 patients, all of which underwent phacoemulsification and intraocular lens (IOL) implantation. After random assignment, 64 eyes received the combination of topical 0.5% moxifloxacin/0.1% dexamethasone drop and 62 eyes received 0.5% moxifloxacin and 0.1% dexamethasone as separate solutions four times a day for 15 days. Baseline and postoperative assessments were made on surgery days -2, 1, 3, 8, and 15. Limitations of this study included its small size and relatively short duration of follow-up.

RESULTS

There was no sign of intraocular infection at any time and only minimal inflammation beyond day 3. Physicians rated bacterial infection to be absent in both groups on days 1, 3, 8 and 15. Ninety-seven percent of patients in each group had < or = 5 cells by day 15. Objective and subjective parameters were essentially the same in both treatment groups (p > 0.05). One patient in the conventional therapy group developed viral conjunctivitis unrelated to the surgery.

CONCLUSION

Treatment with the combined moxiflox acin/dexamethasone eye drops was as effective as conventional treatment in preventing infection and controlling inflammation after phacoemulsification and IOL implantation.

Polymyxin B: similarities to and differences from colistin (polymyxin E)

Hospital-acquired infections due to multidrug-resistant gram-negative bacteria constitute major health problems, since the medical community is continuously running out of available effective antibiotics and no new agents are in the pipeline. Polymyxins, a group of antibacterials that were discovered during the late 1940s, represent some of the last treatment options for these infections. Only two polymyxins are available commercially, polymyxin E (colistin) and polymyxin B. Although several reviews have been published recently regarding colistin, no review has focused on the similarities and differences between polymyxin B and colistin. These two medications have many similarities with respect to mechanism of action, antimicrobial spectrum, clinical uses and toxicity. However, they also differ in several aspects, including chemical structure, formulation, potency, dosage and pharmacokinetic properties.

How to deal with multiple treatment or dose groups in randomized clinical trials?

Multiplicity adjustment in general is currently a controversial topic. This review focuses on the proof of efficacy in randomized clinical trials. The ICH guidelines mandate control of the familywise error rate. Confidence intervals are clinically more appropriate than P-values or yes/no decisions. Therefore, simultaneous confidence intervals are proposed for several designs and aims in clinical trials. The computation of simultaneous confidence intervals for the difference or the ratio is demonstrated by means of real data examples using the R-packages multcomp and mratios. A special problem is the evaluation of dose-finding trials with and without the assumption that the effects increase with increasing doses. Simultaneous intervals are presented not only for one-way layouts and normal distributed endpoints, but also for higher way layouts, generalized linear models, and mixed models. Under importance ordering, the conditional testing of all hypotheses at level alpha will be shown using the intersection-union test principle. Other multiplicity issues (i.e. multiple endpoints, multiple analyses, and subgroup analyses) are discussed.

Dexamethasone-netilmicin: a new ophthalmic steroid-antibiotic combination. Efficacy and safety after cataract surgery

PURPOSE

The purpose of this study was to evaluate both efficacy and safety of a new ophthalmic steroid-antibiotic fixed combination containing dexamethasone and netilmicin in the postsurgical management of cataract surgery.

METHODS

In total, 223 patients were randomly treated with dexamethasone 1 mg/ml plus netilmicin 3 mg/ml (n=148), or dexamethasone 1 mg/ml plus tobramycin 3 mg/ml (n=75, TOBRADEX) four times in a day for 7+/-1 days starting immediately after surgery. Efficacy (anterior chamber (AC) inflammation, conjunctival hyperaemia, corneal and lid oedema, ocular infection, pain, photophobia and tearing) and safety (burning, stinging, blurred vision, intraocular pressure, and visual acuity) were analysed in the operated eye after 1 and 7+/-1 days. A follow-up visit was performed at day 14+/-2. The extent of AC inflammation, measured by slit-lamp according to a standard scoring system, was used as primary efficacy parameter.

RESULTS

At the primary end point (day 7) both fixed combinations were equally effective in reducing postoperative inflammation. The safety profile of the dexamethasone/netilmicin combination was excellent with no evidence of poor local tolerance or adverse reaction.

CONCLUSIONS

A new fixed combination of dexamethasone and netilmicin was effective and safe in controlling ocular inflammation after cataract surgery.

A clinical comparison of two different prednisolone acetate formulations in patients undergoing cataract surgery

PURPOSE

This study was conducted to evaluate the efficacy of two topical steroid prednisolone preparations (Econopred Plus 1%, prednisolone acetate 1%: EPP; Pred Fortedagger 1%, prednisolone acetate 1%: PF) in reducing postoperative inflammation in cataract patients.

METHODS

This was a 4 week, randomized, parallel-group, single-center, active-controlled study. One group of patients received postoperative topical EPP while the other group received postoperative topical PF. Both medications were dosed 4 times per day for 14 days and then BID until the container was empty. Both groups of patients received diclofenac sodium QID for 14 days and hydroxypropyl guar (HP-Guar, Systane) QID for 7 days then PRN (or as directed). The presence of corneal surface keratitis, anterior chamber cells and flare (scales 0-3 for keratitis, 0-5 for cells and 0-4 for flare; 0 = none) was evaluated by slit lamp biomicroscopy.

RESULTS

EPP produced significantly lower (P < 0.05) anterior chamber flare scores 14 days following surgery (mean +/- SD: 0.86 +/- 0.53) than PF (1.08 +/- 0.40). Otherwise, there were no differences observed between the 2 treatments with respect to keratitis, anterior chamber flare or cells at postop days 1, 7, or 28.

CONCLUSIONS

This comparative trial demonstrated that both formulations of prednisolone acetate 1% have similar efficacy in the treatment of postoperative ophthalmologic inflammation.